Fatigue More Severe Than Anticipated in Palliative Medicine

FORT LAUDERDALE, Fla—How common is severe cancer-related fatigue? In a survey study at the Cleveland Clinic, 72 of 172 palliative medicine consult patients contacted said they were too tired to participate. “While fatigue is fairly common in patients with advanced cancer, the extent of their fatigue was surprising,” Kristine Nelson, MD, said at the Cleveland Clinic’s Palliative Medicine 1999 meeting.

Dr. Nelson, director of the Palliative Medicine Research Program at the Cleveland Clinic, said there are limits to patient surveys of fatigue. “You’re basically talking to the patients about symptoms, and you usually don’t attain any information about the cause or mechanism of that symptom,” she said. However, she noted that palliative medicine is a “young science,” and information is needed about the prevalence and severity of symptoms. “Patient surveys are an easy way to attain this information,” she said.

The study included a patient questionnaire as well as collection of data on each patient (age, sex, primary diagnosis, extent of disease, performance status, weight change since diagnosis, and certain laboratory tests). Of the 100 participants in the survey (54 men and 46 women with a median age of 68 years), 27 different cancers were reported, with the most common being lung cancer (26 patients). Most patients (63) had an ECOG performance status of 3.

The median weight change since diagnosis was a loss of 24 pounds (range, +20 to -90). The median laboratory values were hemoglobin, 10.6 g/dL; hematocrit, 32.2 mL/dL; and lactate dehydrogenase (LDH), 234 U/L.

The survey questionnaire asked six questions:

Do you feel fatigued right now?

How fatigued did you feel this past week?

Circle one activity that you consider important. (Cooking, Dressing, Visiting, Driving, Gardening, Family activities, Walking, Shopping, Housework, Social activities)

How would you rate your ability to do this activity?

How was your quality of life this past week?

What does the word fatigue mean to you? (Tired, Lack of energy, Depressed, General weakness, Don’t know, Other)

Questions 1, 2, and 4 were rated on a 100 mm visual analog scale with the following anchors: very fatigued to no fatigue for questions 1 and 2, and impossible to normal for question 4.

In question 1, the median patient rating for current fatigue was 22 mm (range, 0 to 98). For question 2, patients rated their fatigue over the last week at a median of 12 mm (range, 0 to 90).

Most Important Activities

The most common responses for question 3 were walking (13), driving (13), dressing (11), and social activities (11). In question 4, they rated their ability to do these activities at a median of 10 mm (range, 0 to 99).

 “I must admit I’m a little bit perplexed by this because we have other studies that show that families are usually the winners in what’s important to patients’ lives,” Dr. Nelson said. “I can only say that, most likely, since the patients were doing a fatigue questionnaire, they singled out the physical problems—a physical activity that was important that they couldn’t do when they were fatigued.”

In question 5, the majority of patients rated their quality of life as “bad” (69), while 25 said it was “acceptable,” and only 4 considered it “good.”

In question 6, the most common patient definitions for fatigue were lack of energy (41), tired (38), and general weakness (19). Thus, there is no clear, straight-forward definition of the word fatigue.

“This may be one of the significant results of the study,” she said. “So when you ask a patient, ‘Are you tired? Are you fatigued?’ you should be aware that there are many different interpretations of the word, and the clinician and patient may not be talking about the same thing.”